20210578 Ver 1_Certification of Completion_20210331

Transportation and Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] \ FAX: [phone]

Internet: www.ncwaterquality.org

An Equal Opportunity \ Affirmative Action Employer

DWQ Project No.: #20210578 County: Jackson
Applicant: North Carolina Department of Transportation – Division 14
Project Name: Henry Bird Road Culvert Replacement
Date of Issuance of 401 Water Quality Certification: 3.31.2021

Certificate of Completion

Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the 401 Transportation Planning Unit, North
Carolina Division of Water Resources, 1617 Mail Service Center, Raleigh, NC, 27699-1617. This form may be returned to
NCDWR by the applicant, the applicant’s authorized agent, or the project engineer. It is not necessary to send certificates
from all of these.
Applicant’s Certification
I, _Patrick J. Breedlove, Division 14 - Environmental Specialist II, hereby state that, to the best of my abilities, due care
and diligence was used in the observation of the construction such that the construction was observed to be built within
substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and
specifications, and other supporting materials.

Signature: _________________________________________ Date: _______________________________
Agent’s Certification
I, _____________________________________, hereby state that, to the best of my abilities, due care and diligence was used
in the observation of the construction such that the construction was observed to be built within substantial compliance and
intent of the 401 Water Quality Certification and Buffer Rules, the approved plans and specifications, and other supporting
materials.
Signature: ______________________________ Date: _________________________________
Engineer’s Certification ______ Partial ______Final

I, ____________________________________, as a duly registered Professional Engineer in the State of North Carolina,
having been authorized to observe (periodically, weekly, full time) the construction of the project, for the Permittee hereby
state that, to the best of my abilities, due care and diligence was used in the observation of the construction such that the
construction was observed to be built within substantial compliance and intent of the 401 Water Quality Certification and
Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature: ______________________________________ Registration No. ________________
Date ____________________
North Carolina Division of Environmental Quality
Division of Water Resources
Roy Cooper
Governor
James H. Trogdon III
Secretary of Transportation

7/7/2021